Outcomes after hematopoietic cell transplantation among non-English- compared to English-speaking recipients.

Multiple studies have documented that racial/ethnic minority patients are less likely to undergo hematopoietic cell transplantation (HCT) in the United States (US), and if they do, they often have worse outcomes. No studies to our knowledge have compared the outcomes of English-speakers to non-English speakers undergoing HCT in the US. To test our hypothesis that non-English speakers have worse outcomes than English speakers after HCT, all transplants performed between 2015 and 2019 at Fred Hutchinson Cancer Research Center in Seattle, WA, USA were analyzed. Cox proportional hazards models were used to test our hypothesis, adjusting for significant clinical covariates. Out of 2051 patients, 106 (5%) were documented to be non-English speakers. Mortality for non-English speakers was not different than English speakers (adjusted HR 1.02, 95% CI 0.63-1.63, p = 0.95). When the analysis was limited to the allogeneic population, the results were similar to the total population (adjusted HR 1.10, 0.64-1.88, p = 0.73). The risk of grade II-IV acute graft-versus-host disease (GVHD) was higher in the non-English speaking subset: adjusted OR 2.01, 95% CI, 1.02-3.98, p = 0.04. These data suggest that non-English speakers have similar survival compared to English speakers following HCT although they have more acute GVHD.

Theory-Informed Models: Application to Nursing Practice.

The processes for review and confirmation of a theoretical model, its translation into current clinical practice, and the evaluation of outcomes will be presented. The authors' experience at the Seattle Cancer Care Alliance in Washington illustrates the value and relevance of theoretical models in oncology care.

Technology's role in promoting physical activity and healthy eating in working rural women: A cross-sectional quantitative analysis.

AIMS: This exploratory study evaluated sociodemographic predictors of healthy eating and physical activity (PA) in a sample of working rural women and their access to and interest in using technology for health promotion. SETTINGS AND DESIGN: This study is a cross-sectional quantitative analysis. MATERIALS AND METHODS: A 32-item questionnaire was administered to a convenience sample of N = 60 women, working at a regional healthcare facility in the Pacific Northwest. STATISTICAL ANALYSIS: Descriptive statistics characterized PA and healthy eating, barriers and support for PA and healthy eating, and perceived role of technology for health promotion. Chi-square tests for categorical variables evaluated relationships between PA and healthy eating support with behavioral engagement. RESULTS: Only 23% and 25% followed recommended PA and fruit and vegetable consumption guidelines. Those likely to engage in preventive care had higher income and education. Fewer respondents reported barriers to PA than for healthy eating (47% vs. 57%), and those reporting barriers were likely to have lower income and less than a high-school education. Sixty percent reported social support for PA and only 52% for healthy eating. A significant relationship was evident between PA support and PA engagement (P = 0.015). Eighty-two percent used mobile phones to look up health information and 29% did so daily. Almost two-thirds (62%) reported likelihood of using online health information boards to support healthy eating and 45% for PA. CONCLUSION: Working rural women benefit from PA and healthy eating guidance. Attention to sociodemographic predictors may support a tailored digital healthcare approach to promote wellness in this community.

A Dedicated Education Unit and a Novel Resident Nurse Transition-to-Practice Program in an Ambulatory Oncology Setting.

OBJECTIVE: To summarize an innovative initiative in oncology nurse workforce development that addresses critical current and future gaps and encompasses use of dedicated education units for student nurse rotation and a transition-to-practice residency program. DATA SOURCES: Review of institutional data including original pilot analysis and ongoing programmatic metrics (N=8 years), consensus, professional guidelines, and published literature. CONCLUSION: The dedicated education unit serves as a conduit for recruitment into institutional oncology nurse residency positions, and retention rates in the residency program continue to exceed national averages. Subsequent mentoring of these nurses in transition to practice has manifested high rates of promotion into nurse leadership roles year over year. IMPLICATIONS FOR NURSING PRACTICE: Oncology nurse practice incorporates state-of-the-science approved therapies, early phase clinical trial implementation, and evidence-based complex oncology patient care management. A new model of student clinical nurse rotations in ambulatory settings, nurse resident transition to practice, and ongoing leadership mentoring is essential in creating a sustainable, highly skilled, and robust oncology nurse work force.

Outpatient intensive induction chemotherapy for acute myeloid leukemia and high-risk myelodysplastic syndrome.

To improve patient quality of life and reduce health care costs, many conditions formerly thought to require inpatient care are now treated in the outpatient setting. Outpatient induction chemotherapy for acute myeloid leukemia (AML) may confer similar benefits. This possibility prompted a pilot study to explore the safety and feasibility of intensive outpatient initial or salvage induction chemotherapy administration for adults with AML and high-risk myelodysplastic syndrome (MDS). Patients with no significant organ dysfunction and a treatment-related mortality (TRM) score corresponding to a day 28 mortality rate of <5% to 10% were eligible for study. Patients were treated as outpatients with daily evaluation by providers and only admitted to the hospital if mandated by complications. Twenty patients were consented, and 17 were treated. Eight patients received initial induction chemotherapy and 9 received salvage induction chemotherapy. Fourteen patients completed induction chemotherapy administration in the outpatient setting (82.4%; exact 95% confidence interval [CI], 55.8-95.3). Three patients were admitted during the course of chemotherapy administration, 2 for neutropenic fever and 1 for grade 3 mucositis. No patients died within 14 days of the initiation of induction chemotherapy (exact 95% CI, 0-22.9). Results of this pilot study suggest it is feasible to complete outpatient induction chemotherapy in select patients with AML and high-risk MDS. A team including nurses, social workers, medical providers, and pharmacists was key to the successful implementation of outpatient induction.

Patterns of Hand Grip Strength and Detection of Strength Loss in Patients Undergoing Bone Marrow Transplantation: A Feasibility Study.

PURPOSE/OBJECTIVES: To determine the feasibility of measuring hand grip strength (HGS) daily in a population of recipients of bone marrow transplantation (BMT), to describe changes in strength measured by HGS, and to describe relationships between laboratory values (hematocrit, hemoglobin, and absolute neutrophil count) and HGS.
. DESIGN: Prospective, longitudinal, repeated measures, within subject.
. SETTING: Inpatient units at the University of Washington Medical Center in Seattle.
. SAMPLE: 33 patients admitted in preparation for BMT or for complications from BMT.
. METHODS: HGS measured on admission and daily.
. MAIN RESEARCH VARIABLES: HGS, absolute neutrophil count, hemoglobin, and hematocrit.
. FINDINGS: Participants found HGS testing to be relatively easy. Average time to complete testing was 7.2 minutes (SD = 1.95). Nineteen experienced 20% or greater decline in HGS during hospitalization, with nine experiencing decline during the conditioning phase. Age, gender, and hemoglobin correlated with HGS. Strength loss was more likely in those undergoing allogeneic compared to autologous BMT.
. CONCLUSIONS: A majority of patients experienced strength decline during BMT, with a subgroup declining during conditioning. A positive relationship existed between HGS and hemoglobin and hematocrit in participants admitted for conditioning for BMT.
. IMPLICATIONS FOR NURSING: Weakness increases risk for falls. Patients may experience as much as 50% strength loss during the course of hospitalization for BMT. Strength loss occurs in the conditioning phase for some patients.

Caring to Learn and Learning to Care.

The increasing numbers of aging and chronically ill prisoners incarcerated in Western nations is well-documented, as is the growing need for prison-based palliative and end-of-life care. Less often discussed is specifically how end-of-life care can and should be provided, by whom, and with what resources. One strategy incorporates prisoner volunteers into end-of-life services within a peer-care program. This article reports on one such program based on focused ethnographic study including in-depth interviews with inmate hospice volunteers, nursing staff, and corrections officers working in the hospice program. We describe how inmate volunteers learn hospice care through formal education and training, supervised practice, guidance from more experienced inmates, and support from correctional staff. We discuss how emergent values of mentorship and stewardship are seen by volunteers and staff as integral to prison hospice sustainability and discuss implications of this volunteer-centric model for response-ability for the end-of-life care of prisoners.

Essential Elements of an Effective Prison Hospice Program.

As the number of prison inmates facing end-stage chronic illness grows, more prisons across the U.S. must address the need for end-of-life care. Many will likely need to develop a plan with potentially limited resources and external support. This case study presents one long-running model of care, the Louisiana State Penitentiary Prison Hospice Program. Based on field observations and in-depth interviews with hospice staff, inmate volunteers and corrections officers, we identify five essential elements that have contributed to the long-term operation of this program: patient-centered care, an inmate volunteer model, safety and security, shared values, and teamwork. We describe key characteristics of each of these elements, discuss how they align with earlier recommendations and research, and show how their integration supports a sustained model of prison end-of-life care.

Idarubicin, cytarabine, and pravastatin as induction therapy for untreated acute myeloid leukemia and high-risk myelodysplastic syndrome.

Previous studies suggest that idarubicin/cytarabine(ara-C)/pravastatin (IAP) is an active salvage regimen for patients with AML. We therefore investigated this regimen in patients with newly-diagnosed AML or MDS (≥10% blasts). Patients were eligible if the anticipated treatment-related mortality (TRM) was <10%. Patients received pravastatin (1,280 mg/day po; days 1-8), cytarabine (1.5 g/m(2) /day; days 4-7), and idarubicin (12 mg/m(2) /day, days 4-6). Up to 3 cycles of consolidation with a shortened course was permitted. The primary endpoints were "good CR" rate (CR on day 35 without minimal residual disease) and TRM in the first 28 days. The study was to stop if after each cohort of 5 patients (a) the Bayesian posterior probability was < 5% that the true "good CR rate" was ≥ 70% or (b) the posterior probability was >25% that the TRM rate was ≥5%. Twenty-four patients were included. Conventional CR was achieved in 15 (63%) patients but only 12 (50%) achieved "good CR". 4 of 12 (33%) patients with "good CR" relapsed at median of 16 weeks (10.5-19). Five (21%) patients had refractory disease. Survival probability at 1 year was 72% (48.7-64). Two (8.3%) patients died within 28 days from multiorgan failure. The most common grade 3-4 adverse effects were febrile neutropenia (75%) and diarrhea (25%). Based on the stopping rules accrual ceased after entry of these 24 patients. IAP did not meet the predefined efficacy criteria for success. Therefore, we would not recommend this regimen for phase three testing in this patient subset.

Outpatient bendamustine and idarubicin for upfront therapy of elderly acute myeloid leukaemia/myelodysplastic syndrome: a phase I/II study using an innovative statistical design.

Combinations of agents may improve outcomes among elderly acute myeloid leukaemia (AML) and high-risk myelodysplastic syndrome (MDS) patients. We performed an adaptive phase I/II trial for newly-diagnosed AML or high-risk MDS patients aged ≥50 years using a Bayesian approach to determine whether 1 of 3 doses of bendamustine (45, 60, 75 mg/m(2) days 1-3), together with idarubicin (12 mg/m(2) days 1-2), might provide a complete response (CR) rate ≥40% with <30% grade 3-4 non-haematological toxicity. We treated 39 patients (34 AML; five MDS with >10% marrow blasts; median age 73 years). None of the three bendamustine doses in combination with idarubicin met the required CR and toxicity rates; the 75 mg/m(2) dose because of excess toxicity (two of three patients) and the 60 mg/m(2) dose because of low efficacy (CR rate 10/33), although no grade 3-4 non-haematological toxicity was seen at this dose. Median survival was 7·2 months. All patients began treatment as outpatients but hospitalization was required in 90% (35/39). Although we did not find a dose of bendamustine combined with idarubicin that would provide a CR rate of >40% with acceptable toxicity, bendamustine may have activity in AML/MDS patients, suggesting its addition to other regimens may be warranted.

Outpatient management following intensive induction chemotherapy for myelodysplastic syndromes and acute myeloid leukemia: a pilot study.

Due to infectious and bleeding risks, adults with acute myeloid leukemia or high-risk myelodysplastic syndromes typically remain hospitalized after remission induction chemotherapy until blood count recovery. Here, we explored the medical and financial effects of discharge immediately after chemotherapy completion with close outpatient follow up. Within 12 months, 15 patients fulfilling both medical and logistical criteria were discharged early, whereas 5 patients meeting medical criteria only served as inpatient controls. No patient died. Patients discharged early spent a median of 8 days (range 3-36 days), or 54% of their study time, as outpatients. These patients required less time on intravenous antibiotics (6 vs. 16 days; P=0.11), received fewer red blood cell transfusions (0.25 vs. 0.48 units/day; P=0.08), and incurred lower median daily charges ($3,270 vs. $5,467; P=0.01) than controls. Thus, early discharge of selected patients appears, safe and may reduce cost and resource utilization. (ClinicalTrials.gov Identifier: NCT00844441).

"I had already made up my mind": patients and caregivers' perspectives on making the decision to participate in research at a US cancer referral center.

BACKGROUND: Hematopoietic cell transplants (HCTs) are associated with high morbidity and mortality, which complicate the decision-making process for people considering HCT clinical trials. There is a lack of research examining longitudinally how patients make clinical trial participation decisions in US cancer referral centers. OBJECTIVE: A qualitative study was conducted to examine how patients and their family caregivers decide to participate in HCT research at a US cancer referral center. METHODS: Semistructured interviews were conducted with 25 patients enrolled in early-stage phase 2 HCT research studies and with 20 family caregivers. Interviews were conducted before HCT and approximately days 80 and 365 after HCT. RESULTS: Most patients (92%) and their caregivers (75%) decided to participate in research well before consent conferences at the cancer referral center. Patients' reasons for deciding to participate included having "no other option," seeking a cure, and following their home oncologists' recommendations. CONCLUSION: Currently, US researchers are primarily guided by Federal regulations that view the decision-making process as a cognitive one. Findings confirmed cognition was a part of consent; however, most patients made the decision to participate in high-risk clinical trials long before they had been apprised of the specific information about the study and before the consent conference. IMPLICATIONS FOR PRACTICE: The high risk of death from the disease and/or the HCT underscored the emotional component of decision making and affirmed that researchers need to acknowledge this emotional component to meet the ethical imperative of providing "informed consent."

Decision-making in the diagnosis and treatment of leukemia.

OBJECTIVES: To review the precepts of decision-making for people diagnosed with leukemia. DATA SOURCES: Professional journals, research studies, review articles, and personal experience. CONCLUSION: Decision-making is one of the most complex and demanding tasks faced by people diagnosed with leukemia. There are multiple dimensions of decision-making, including access to information, psychosocial support, spiritual support, education options for treatment and participation in clinical trials. IMPLICATIONS FOR NURSING PRACTICE: Health care professionals are integral to the decision-making process for people diagnosed with leukemia and are involved in most situations where decisions must be made relative to treatment, research, and symptom management.

Nursing implications of mylotarg: a novel antibody-targeted chemotherapy for CD33+ acute myeloid leukemia in first relapse.

PURPOSE/OBJECTIVES: To review the nursing implications of gemtuzumab ozogamicin (Mylotarg(r), CMA-676, Wyeth Pharmaceuticals, Philadelphia, PA), a novel monoclonal antibody-targeted chemotherapy agent for relapsed acute myeloid leukemia (AML). DATA SOURCES: Published articles, abstracts, book chapters, manufacturer information, unpublished clinical trial data, and personal experiences with gemtuzumab ozogamicin. DATA SYNTHESIS: Conventional chemotherapy for AML is associated with toxicities that often limit treatment options when AML relapses. Gemtuzumab ozogamicin is a humanized recombinant anti-CD33 monoclonal antibody linked to calicheamicin, a potent cytotoxic agent. The antibody targets the CD33 antigen found on the surface of leukemic blast cells and myeloid precursors. This targeting effect reduces the toxicity of gemtuzumab ozogamicin. The efficacy and tolerability of gemtuzumab ozogamicin have been documented in relapsed AML, particularly in patients 60 years of age or older, who often have no other treatment options. As with other monoclonal antibody therapies, an "infusion syndrome" (i.e., fever and chills) may occur but can be managed effectively when administration guidelines are used. CONCLUSIONS: Gemtuzumab ozogamicin is the first of a new class of targeted therapies for the treatment of relapsed AML. A number of implications for nurses exist. IMPLICATIONS FOR NURSING: Nurses must be knowledgeable about gemtuzumab ozogamicin preparation and administration, patient selection and monitoring, and intervention procedures. This knowledge is necessary to accurately inform patients and their families of the possible course of treatment and potential side effects.